Inject Or Not To Inject? That's the Question...

We have all been there before, that pain that will not go away.  It seems to wake you up at night, hurts when you take that first step, maybe even seems to catch your breath.  That's when you call me, or at least someone like me. (Or if your my family member or friend, you text in a panic :)  It is human nature to want a pill, cream, or patch to take the hurt away.  None of us are immune, and if you are in my family you tend to get hurt a little more often!

Many times I have seen a patients in a similar situation and they too want the aching or stabbing to stop in their given joint.  The topic of steroid injections comes up often in this scenario. Where steroid injections can be helpful in reducing pain, they should also be approached as an infrequent or one time treatment.  Steroids are not a benign medication and should not be treated like they are a Flintstones vitamin.  Unfortunately, I do see some people who have had many injections over the course of their lives into the same area.  This is not necessarily the best practice when it comes to our joints.

Using my uncle as an example: he had terrible arthritis of his knees.  He had limped around for years in pain, failed injections. therapy, and knee scopes.  If he had chosen to get steroid injections every 3-6 months in his knees for years he would have only treated his symptoms.  Instead he treated the problem and got both knees replaced and is very happy.  Having one or two steroid injections get you through an injury maybe helpful. However, for someone with a chronic arthritic problem, continued injections do not addressing their underlying problems.

Also, studies have shown that repeated steroid injections to the same area in a short amount of time can be destructive to the tissues.  Detrimental Effect of Repeated and Single Subacromial Corticosteroid Injections on the Intact and Injured Rotator Cuff, in the American Journal of Sports Medicine tests one and three steroid injections in the shoulders of rats.  The researchers had rats with both non injured shoulders and some with rotator cuff tears. Then they either gave them saline injections, one steroid injection, or three steroid injections over 3 weeks. The rotator cuffs were then tested for failure.  The single injection rats took 17% less load to cause the cuffs to fail then the saline group, and the triple injection took 32% less load to fail.1  Also, they found the bone volume was decreased in the triple injection group and the stiffness of the cuff tissue decreased by 50% in the triple injection group.1   What does it all mean?  Multiple injections can cause damage to the tissues within the joint. 
  
I wish I could tell you that everything that made you feel better was good for you.  But that just in not true, or responsible.  Steroid injections have a great place in orthopedics and medicine but often get overused because people want a quick fix.  Remember to look for a solution to the problem if possible.  As with everything there are always gray areas and it is best to discuss this with your provider individually.  


Sources:

1. Maman, E., Pritsch, T., & Morag, G. et al (2015, July 27). Detrimental Effect of Repeated and Single Subacromial Corticosteroid Injections on the Intact of Injured Rotator Cuff: A Biomechanical and Imaging Study in Rats. The American Journal of Sports Medicine, 44(1), 177-182. 

Stem Cell Answers

Lately I have had patients asking me about stem cell injections for arthritis, newly popular treatment for a variety of aliments. Stem cells are immature cells that have not yet "differentiated" or formed into their final cell type.  This makes them very useful in regenerative medicine and also controversial.

Stem cells can be found in many tissues through out the body including bone marrow, fat, muscle, and brain tissue. 1  Stem cells can also be harvested from human embryos. This particular topic is very controversial and not on our agenda for today.  So lets just stick to what we call "adult" stem cells, or those harvested from grown humans.  The beauty of an undifferentiated stem cell is in its future.  Much like a young college co-ed, it doesn't know what exactly it will be when it grows up, but the world is often its oyster.

Kelly Hotchkiss, student, VCU Department of Biomedical Engineering, School of Engineering Hotchkiss’ image shows human mesenchymal stem cells that present a spread pattern of attachment after being prepared on a glass surface." 2

Depending on what tissue the stem cell is harvested from will determine what cell lines it could potentially form.  For example, in orthopedics we love to use the bone marrow because it contains a stem cell known as the mesenchymal cell (MSC).1  This cell line has the potential to turn into bone and cartilage.1  Other cell lines in bone marrow have potential to turn into other blood cells, etc.  This is useful in certain cancer treatments when patients are in need of more healthy cells/blood.  Also, once implanted it is thought that the cell is actually influenced by the cells around it to differentiate into the same type of tissue.1  A kind of scientific peer pressure if you will!

Mesenchymal cells can be harvested from different areas of the body.  The characteristics of the cells may vary slightly depending on the harvest site, but the important factor is if the MSC can turn into a "chondrocyte" or cartilage cell.  For this reason many surgeons like to use bone marrow, intuitively one would think that MSC from bone would have a high potential to turn into bone and cartilage tissues.  Also these cell lines are the most studied forms, with experiments dating back to the 1960s.  More recently fat has been used as a donation site for stem cells.  Adipose (fat) tissue also contains mesenchymal cells and as one article put it, "adipose is an abundant and easily accessible source." 3  So essentially we have A LOT more fat to choose from as a society, why not use it!

Bone marrow is usually harvested from the hip in the operating room under anesthesia.  Adipose tissue can be taken from several areas including the stomach, love handles, and buttocks.  Once harvested it is treated to remove excess cells and spun down using a machine called a centrifuge to get MSCs.  The cells are then re-implanted into the knee (for example) in the area of the cartilage defect.  Post operative protocols are varied depending on surgeon but may include non-weight baring for a period of time, braces, and physical therapy.

Centrifuge

These procedures are still new and considered experimental by insurance companies.  This makes them cost more money out of pocket unfortunately.  Where there is exciting research being done on the topic the results vary from paper to paper and I would consider the jury still out on some of the overall conclusions.  Before undergoing these injections make sure you have a conversation with your provider and understand exactly what to expect.

   

         
Sources:

1.  http://stemcells.nih.gov/info/basics/Pages/Default.aspx

2. https://news.vcu.edu/article/Small_wonders_The_microscopic_images_currently_on_display_at

3. Koh, Y. G., MD, Kwon, O. R., MD, & Kim, Y. S., MD. (2014). Second look arthroscopic evaluation of cartilage lesions after mesenchymal stem cell implantation in osteoarthritic knees. The American Journal of Sports Medicine, 42(7), 1628-1637. Retrieved April 12, 2016, from www.sagepub.com/journalsPermissions.nav.